Applicant’s Name / Agent Name
Mailing Address / Address
PROPOSED EFFECTIVE DATE: FROM: TO:
12:01 A.M., Standard Time at the address of the Property
COVERAGE INFORMATION
Perils to be Insured: DP-1 DP-3
Fire E.C VMM Premises Liability Personal Liability
Residence Burglary Deductible: $
Mortgagee #1:
Address: Loan No.:
Mortgagee #2:
Address: Loan No.:
Dwelling #1 Limits: / Dwelling #2 Limits:
$ / a. / Masonry Frame EIFS
Log—Hand hewn
Log—Milled Log / $ / a. / Masonry Frame EIFS
Log—Hog hewn
Log—Milled Log
b. / 1 family 2 family
3 family 4 family / b. / 1 family 2 family
3 family 4 family
c. / Owner Tenant Renovation / c. / Owner Tenant Renovation
d. / Vacant Builders Risk
Seasonal Short-Term Rental / d. / Vacant Builders Risk
Seasonal Short-Term Rental
e. / Located at: / e. / Located at:
$ / Other Structures—describe: / $ / Other Structures—describe:
$ / On contents in the above dwelling / $ / On contents in the above dwelling
$ / Residence Burglary / $ / Residence Burglary
$ / Additional Living Expense/Loss of Use / $ / Additional Living Expense/Loss of Use
$ / Premises Liability/Personal Liability / $ / Premises Liability/Personal Liability
$ / Medical Payments / $ / Medical Payments
PROPERTY INFORMATION
1. If vacant, how long has dwelling been vacant?
2. If seasonal or short-term rental, is there a caretaker or property manager? Yes No
3. If vacant, seasonal or short-term rental, how often is dwelling checked on?
4. Was dwelling inspected by agent? Yes No
Comments:
5. Does agent recommend risk? Yes No
Comments:
6. Is there a swimming pool? Yes No
If yes:
Fenced? Yes No
Locking Gate? Yes No
7. Year of Construction: Square Feet: Cost per square foot: $
Year of building updates in:
Wiring: Year Full Partial Type: Knob & Tub Fuses Circuit Breakers
Roofing: Year Full Partial Type:
Plumbing: Year Full Partial
Heating & Air Conditioning: Year Full Partial
Physical condition of buildings:
8. Fire Protection Class: Fire District:
Distance from coastal water (Includes an ocean, gulf, bay or sound):
Distance to hydrant:
Distance to fire station (Indicate miles):
9. Primary source of heat:
10. Is there a wood stove on premises? Yes No
If wood burning stove, attach completed questionnaire and photo.
11. Is dwelling under construction or being renovated? Yes No
If yes, name of licensed contractor:
Number of years experience: Project completion date:
Extent of renovation:
12. Applicant’s occupation(s):
Applicant’s phone number:
13. Are any business pursuits conducted on the premises? Yes No
If yes, describe:14. Firearms kept on premises? Yes No
If yes, Firearms Questionnaire required.
15. Trampoline on premises? (Trampoline will be excluded from Liability coverage) Yes No
16. Any animals? Yes No
Doberman Pinschers, Rottweiler, Staffordshire Bull Terriers, Chow Chow, wolf hybrids, Bullmastiff, American Staffordshire Terrier, Akita, Rhodesian Ridgebacks, Cane Corso, and Pit Bull Terrier will be excluded. This includes any crossbreeds of these animals.
If yes, any bite/aggressive behavior history? Yes No
If yes, describe:17. Acreage? Yes No
If yes, number of acres: Usage:
18. Has any company canceled or refused coverage to the applicant (not applicable in Missouri or California)? Yes No
Comments:19. Previous insurance carrier:
Policy number: Expiration date:
If no previous carrier, why (not applicable in Missouri or California)?20. Any losses at this location or any other location owned/rented within the last three years? Yes No
If yes, provide details:21. Any bankruptcy or foreclosure proceedings filed? Yes No
Reason:Opened Closed Date Closed:
ATTACH PHOTO WITH COMPLETED APPLICATION.
NOTICES AND FRAUD WARNINGS
By submitting this application, I am applying for issuance of a policy of insurance and, at its expiration, for appropriate renewal policies issued by Pacific Coast E&S Insurance Services. I understand and agree that any information about me that is contained in, or that is obtained in connection with, this application or any policy issued to me may be used by any company within Pacific Coast E&S Insurance Services to issue, review, and renew the insurance for which I am applying. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME:
Please send completed application to , and / or
DWG APP Page 1 of 3
Pacificcoastes.com / Santa Rosa / T 880-772-8538 / F 707-573-9761Seattle / T 800-528-5695 / F 206-329-7096